Which states are facing efforts to reverse Medicaid expansion?

Missouri, Oklahoma, and South Dakota — the only three states where voters embedded Medicaid expansion directly into their state constitutions — are facing Republican-led efforts to put the issue back on the ballot.

Why are Republicans targeting these specific states?

These three states are uniquely vulnerable because voters approved Medicaid expansion through constitutional amendments, bypassing GOP-controlled legislatures. Republicans are now seeking to undo or modify those amendments via new ballot measures.

What changes are Republican lawmakers proposing to Medicaid expansion?

Proposals vary by state but include adding work requirements to the expansion population in Missouri, while Oklahoma and South Dakota lawmakers are pursuing similar ballot measures framed as giving voters a second look at prior decisions.

GOP Lawmakers Push to Reverse Medicaid Expansion in 3 States

Three Republican-controlled state legislatures are moving to put Medicaid expansion back before voters in Missouri, Oklahoma, and South Dakota, targeting the only states where voters locked the program into their constitutions directly.

Missouri and Oklahoma both passed those constitutional amendments in 2020. South Dakota followed in 2022. All three measures required state Medicaid programs to cover adults under 65 who earn at or below 138% of the federal poverty level, which translates to $22,024 annually. The ballot approach wasn’t accidental. Expansion advocates chose the constitutional route because GOP-dominated legislatures had been blocking the policy through standard channels for years.

It worked. Now Republicans want a rematch.

In Missouri, state Rep. Darin Chappell is backing a new ballot measure that would attach work requirements to the expansion population. House Majority Leader Alex Riley, also a Republican, has been engaged in those talks inside the Missouri House. In Oklahoma and South Dakota, the Republican push follows a similar playbook: let voters look again at what they approved a few years back, with fresh information about what it costs.

That “fresh information” framing connects directly to what’s happening in Washington. President Donald Trump signed a broad tax and spending package that the Michigan Advance reports is projected to cut federal Medicaid spending by an estimated $886.8 billion over the next decade. The cuts are driven largely by new federal work requirements, which the Congressional Budget Office’s analysis projects will move large numbers of people off the rolls. Under the Affordable Care Act, the federal government has been covering 90% of expansion costs. That’s the number critics have never trusted.

Curtis Shelton, policy director for the Oklahoma Council of Public Affairs, a right-leaning think tank, says the federal shift has changed the math in ways that don’t allow states to look away.

“Now that people have seen just how costly the program is going to be, I think it’s fair to ask voters whether or not they want to reconsider that initial vote,” Shelton said. “We don’t really have sustainable options to fund that. So it’s either going to come from massive tax increases or from benefits being cut for your traditional Medicaid population.”

Shelton’s argument isn’t fringe inside Republican circles in 2026. It’s the central logic behind all 3 of these state-level campaigns.

Michigan isn’t Missouri. The state expanded Medicaid back in 2013 through the legislature, not a constitutional amendment, under what became the Healthy Michigan Plan. That structural difference is significant. It means Lansing doesn’t face the same procedural hurdle of going back to voters. The legislature can move on its own. Michigan now covers roughly 2.7 million residents through Medicaid, a number that makes any federal funding disruption feel like a budget earthquake, not a rounding error.

That legislative flexibility is a double-edged thing. If federal matching dollars erode under the Trump-era cuts, Michigan’s Republican majority at the Capitol doesn’t need a constitutional campaign to act. It can move faster, with less public friction. What’s unfolding in Missouri and Oklahoma isn’t just a regional story about states that went the ballot route. It’s a signal about where the national pressure on expansion is heading, and Michigan is watching it play out from a position where it can’t claim the constitutional protection those three states once thought they had.

$886.8 billion in projected federal cuts doesn’t hit every state the same week. It lands in stages, through regulatory changes, work requirement enforcement, and funding formula adjustments. But the direction isn’t in doubt. States that built coverage gains on a 90% federal match are now doing the math on what happens when that assumption softens.

In Missouri, Oklahoma, and South Dakota, Republican lawmakers are betting that voters who said yes to expansion in 2020 and 2022 might say something different if the question includes a price tag. Whether that bet is right or wrong, Michigan is paying attention.